Survey of the Public Health Nutrition Workforce:

Transcription

1 Survey of the Public Health Nutrition Workforce: Submitted October 29, 2007 to the Association of State and Territorial Public Health Nutrition Directors Betsy Haughton, EdD, RD Professor Director, Public Health Nutrition and Alexa George, MPH, RD Graduate Research Assistant Department of Nutrition The University of Tennessee, Knoxville

2 Survey of the Public Health Nutrition Workforce: Prepared for: U.S. Department of Agriculture Food and Nutrition Service 3101 Park Center Drive Alexandria, VA Project Officer: Stephanie Cooks, Supplemental Food Programs Division Prepared by: Betsy Haughton and Alexa George for Association of State and Territorial Public Health Nutrition Directors Johnstown, PA Project Team Leader: Susanne Gregory, MPH This research was funded, in part, through Cooperative Agreement No.USDA-FNS-WISP-04- PA, with the Food and Nutrition Service, U.S. Department of Agriculture. The opinions or conclusions expressed herein do not, however, necessarily reflect those of the Food and Nutrition Service, U.S. Department of Agriculture.

3 i Table of Contents Executive Summary...1 Background...4 Goals...8 Study Methods...9 Study Findings...13 WIC s Presence in the Public Health Nutrition Workforce...13 Agency of Employment and Primary Work Location of the Public Health Nutrition Workforce...13 Job Classification of the Public Health Nutrition Workforce...15 Years of Practice in Nutrition/Dietetics, Public Health Nutrition, and WIC...19 WIC and Non-WIC Workforce...19 WIC Workforce...19 Non-WIC Workforce...21 Personnel Management and Budget Responsibilities of the Workforce...22 Major Areas of Practice...31 Employment Status...36 Salaries...38 Sources of Funding for the Public Health Nutrition Workforce...41 Academic Preparation, Credentials, Training, and Training Needs...45 Academic Preparation...45 Core Public Health Course Work...46 Credentials of Workforce...53 Attendance in Continuing Education Courses...58 Training Needs...59 Affiliation with Professional Organizations...69 Geographical Distribution of the WIC Workforce Respondents...71 Diversity...73 The Aging Public Health Nutrition Workforce...81 Evaluation of Web-Based Survey Administration...83 Limitations of the Study...87 Conclusions...89 Appendices...92 Appendix A ASTPHND Data and Epidemiology Committee and Project Team...93

4 Appendix B Training Materials...95 Appendix C Survey Instruments: Print for Filled and Vacant Positions Appendix D Study Design ii

5 iii List of Tables Table 1. Core Data Elements Recommended in Enumerating the Public Health Workforce Compared to Data Collected in the ASTPHND Survey...7 Table 2. Response Rates Reported by States for Filled Positions...12 Table 3. WIC and Non-WIC Job Functions (Question 7)...13 Table 4. Agency of Employment (Question 1)...14 Table 5. Primary Work Location (Question 2)...15 Table 6. Titles and Descriptions of Public Health Nutrition Job Classifications From Personnel in Public Nutrition for the 1990s...16 Table 7. Job Classifications (Question 4)...18 Table 8. Years of Practice in Nutrition and Public Health Nutrition (Questions 5)...20 Table 9. Years of Practice in Nutrition and Public Health Nutrition (Questions 5 and 6) Comparison of WIC Professionals and WIC Paraprofessionals...20 Table 10. Years of WIC Experience (Question 8) A Comparison of WIC Professionals and Paraprofessionals...21 Table 11. Total FTEs (including nutrition and non-nutrition positions) Directly Supervised by Professional Job Classifications of Filled Positions (Question 9)...24 Table 12. Nutrition FTEs Supervised by Professional Job Classifications of Filled Positions (Question 10)...25 Table 13. Health Professional FTEs Supervised by Professional Job Classifications of Filled Positions (Question 11)...26 Table 14. Support Staff FTEs Supervised by Professional Job Classifications of Filled Positions (Question 12)...27 Table 15. Paraprofessional FTEs Supervised by Professional Job Classifications of Filled Positions (Question 13)...28 Table 16. Total FTEs Directly and Indirectly Supervised by Professional Job Classifications of Filled Positions (Question 14)...29 Table 17. Budget Responsibility by Job Classification (Question 15)...30 Table 18. Primary Area of Public Health Practice According to Category of Core Public Health Functions--Number of Respondents in Filled Positions (Question 25)...32 Table 19. Estimated Time Spent in Direct Services Per Month for Filled Positions (Question 16)...33 Table 20. Percent of Time Spent in Direct Services for Filled Positions (Question 16)...34 Table 21. Percent of Time in Direct Services by WIC Professionals for Filled Positions (Question 16)...35 Table 22. Client Population Seen by Workforce (Filled Positions) Whose Primary Area of Practice is Direct Service (Question 26)...35 Table 23. Employment Status of Filled Positions (Question 19)...36 Table 24. Proportion of Workforce in Full-Time and Part-Time Positions (Questions 17 and 18)...36 Table 25. Method of Payment for Contract Workers in Filled Positions (Question 20)...37 Table 26. Employee Benefits of Contracted and Employed Workforce (Question 23)...37 Table Annual Median Salary for Filled Positions (Question 21)...39 Table 28. Minimum Annual Median Salary for Filled and Vacant Positions (Question 22)...40

6 Table 29. Maximum Annual Median Salary for Vacant Positions (Question 21)...41 Table 30. Full-time Equivalents Per Funding Source A Comparison of 1994, , and (Question 24)...42 Table 31. Full-Time Equivalents Per Funding Source (Question 24)...44 Table 32. Academic Preparation of the Public Health Nutrition Workforce (Question 27)...48 Table 33. Academic Preparation of WIC Professionals and Paraprofessionals (Question 27)..49 Table 34. Highest Academic Degree Reported by WIC Workers (Question 27)...50 Table 35. Core Public Health Course Work Among Personnel Without a Public Health Degree (Question 28)...51 Table 36. Core Public Health Course Work at Schooling Level Among Personnel Without a Public Health Degree (Question 28)...52 Table 37. Certifications and Credentials (Question 29)...53 Table 38. Certifications and Credentials of the WIC Nutrition Workforce (Question 29)...56 Table 39. Steps Taken to Become Registered Dietitians by Non-RDs (Question 31)...57 Table 40. Steps Taken to Become Dietetic Technicians, Registered by Non-DTRs (Question 32)...57 Table 41. Agency of Employment of Staff in Nutrition Courses (Question 33)...61 Table 42. Proportion of Each Job Classification that Attended Nutrition Courses (Question 33)...62 Table 43. Number of Respondents Indicating Attendance at Each of the Nutrition Courses for Filled Positions (Question 33)...64 Table 44. Perceived Training Needs of the WIC Workforce Top 10 Choices (Question 34)...66 Table 45. Perceived Training Needs of the Non-WIC Workforce Top 10 Choices (Question 34)...67 Table 46. Membership in Professional Organizations for WIC and Non-WIC Workers (Question 35)...70 Table 47. Membership in Professional Organizations for WIC Professionals and Paraprofessionals (Question 35)...71 Table 48. Distribution of WIC Workforce Respondents and WIC Participants by State (Question 7)...72 Table 49. Gender of the Workforce (Question 37)...75 Table 50. Ethnicity of the Workforce (Question 40)...75 Table 51. Racial Background of the Workforce as One Race or Two or More Races Reported (Question 41)...75 Table 52. Racial Background of the Workforce (Question 41)...77 Table 53. Diversity of the US Population. PH Nutrition Workforce, and WIC Participants...78 Table 54. Primary and Secondary Languages Reported by WIC and Non-WIC Respondents (Question 42)...80 Table 55. Intend to Retire Within the Next 10 Years (Question 39)...82 iv

7 1 Executive Summary The Association of State and Territorial Public Health Nutrition Directors (ASTPHND) with support from a cooperative agreement with the U.S. Department of Agriculture, Food and Nutrition Service s (USDA, FNS) Special Supplemental Nutrition Program for Women, Infants and Children (WIC) and with assistance from the Public Health Nutrition Program at The University of Tennessee, Knoxville conducted a national enumeration census of the public health nutrition workforce (including territories). The workforce survey was the latest in a series of survey administrations ASTPHND has conducted since State/territorial public health nutrition directors and/or ASTPHND designees conducted the census reported on in this document from ; the previous survey was administered in For the first time, the survey was administered primarily in an on-line format. The goals of the workforce survey were: To identify trends in the public health nutrition workforce. To determine the capacity of the public health nutrition workforce in accomplishing program goals and meeting priority needs To identify training needs of WIC personnel in relation to their job responsibility, credentials, education, and longevity To measure qualifications of WIC nutrition staff in all states and territories. To evaluate use of a Web-based survey strategy to collect and analyze personnel data. To assist USDA and state public health agencies in planning and evaluating their recruitment and retention efforts. Full and part-time public health nutrition professionals and paraprofessionals employed or contracted by public health nutrition programs or services under the purview of the official state/territorial health agency were included in the census. As in previous survey administrations, there was variation between programs administered by each state s health agency. Therefore, the personnel included in the census in each state may have varied according to which programs were administered by the state health agency. As a result, generalizations across states and overall conclusions must be made with caution. The census was developed with leadership of a Project Team that included members of ASTPHND and The University of Tennessee, and guidance from the ASTPHND Data and Epidemiology Committee. A 42-item, fixed response survey instrument was developed, pilottested and implemented for the census, designed in large part from the survey instrument to enable comparisons of the two workforces. The survey instrument was converted to an on-line format that required approximately 20 minutes to complete (compared to 26 minutes to complete the print version). The survey instrument included items on agency and location of job practice, job classification, years of practice, supervisory and fiscal responsibility, time in direct client services, salary and funding source, area of practice, education, certifications or credentials, training and perceived training needs, participation in professional organizations, and personal characteristics (gender, race and ethnicity, and primary and secondary languages). For the first time, the survey instrument contained items on benefits, year born, and

8 2 retirement intentions within the next 10 years. The survey instrument was pilot-tested in April 2005; data collection was initiated in August 2006 and completed in March Data were collected on 10,683 positions, including 371 positions vacant at the time of data collection. The estimated response rate for filled positions, based on the reports of State Contacts responsible for survey administration within their states, was 80% (10,312/12,886). All 50 states, the District of Columbia and Guam participated in the survey. State-specific response rates ranged from a high of 100% (Delaware) to a low of 29.8% (Minnesota). In addition, response rates could not be determined for Ohio and Rhode Island because the number of position identifiers administered was not reported. The most significant improvement in response rate for this survey administration compared to was participation of Idaho, the only state that did not participate then. Highlights This information is described in greater detail in the study findings section. The majority of public health nutrition workers were employed (or contracted) by the government. Almost 70% of public health nutrition positions were employed or contracted by state or local government health agencies. Most of the WIC workforce was employed at the local level (43.5%), while most of the non-wic workforce was employed at the state level (35.0%). Employment by private non-profit organizations decreased for the WIC workforce from More than half of positions overall (53.4%) and within WIC (53.0%) were located at central offices of state, district/regional, and local health agencies or field office/clinics of government health agencies WIC remained the primary funding source for the public health nutrition workforce. Nearly 90% (88.6%) of the workforce worked within WIC, which was a slight decrease from (90.4%). WIC also funded 79.3% of all full-time equivalents (FTEs), which was also a slight decrease from (81.0% and 81.7% in 1994). USDA as a whole funded 83.4% of workforce FTEs, while the U.S. Department of Health and Human Services (DHHS) accounted for 4.7% and state funding for 4.75% (an increase from ). The public health nutrition workforce increasingly was contracted, rather than employed, and/or part-time. While the majority remained employed (93.6%), 6.4% of the workforce was contracted, an increase from (3.7%). Also, most positions (77.9%) were full-time, but the proportion of full-time WIC employees decreased from (78.0% vs. 81.5%). The workforce remained predominantly professional, with 71.4% of public health nutrition positions classified as professional, 24.1% classified as paraprofessional, and 4.5% classified as other. Paraprofessionals represented 26.4% of the WIC workforce, compared to only 6.7% of the non-wic workforce. At the request of USDA, FNS, an additional position class, Breastfeeding Peer Counselor, was added to the survey instrument. Over 11% (11.4%) of the overall workforce and 12.6% of the WIC workforce was classified as Breastfeeding Peer Counselor.

9 3 The public health nutrition workforce remained very experienced. Over half (51.8%) of the workforce had at least 10 years of dietetics/nutrition experience and 42.7% had at least 10 years of public health nutrition experience. While 51.6% of the WIC workforce had at least 10 years of dietetics/nutrition experience, 29.6% had less than 5 years of experience in dietetics/nutrition. This indicates a workforce that was both relatively young and seasoned, in terms of experience. The proportion of WIC nutrition personnel with 1-9 years of dietetics/nutrition experience decreased compared to , suggesting that retention remained a concern for the public health nutrition workforce infrastructure, particularly as leadership. The proportion of Registered Dietitians (RDs) and Dietetic Technicians, Registered (DTRs) decreased from While 41.2% of the workforce surveyed in reported being an RD, only 36.8% of the workforce reported similarly. This continued the downward trend from 1994, when 42.1% of the workforce was an RD. Only 4.1% of the workforce was dietetic registration-eligible. DTRs comprised only 1.6% of the workforce. The public health nutrition workforce was more diverse than the general U.S. population, but less so than WIC participants. Almost 95% of the workforce was female, 70.0% was not Hispanic/Latino, and 69.9% was white. The WIC workforce was more diverse with 20.9% reporting being Hispanic/Latino and almost one-quarter (23.4%) being of a single or two or more races other than white (compared to 18.1% of the non-wic workforce). Over 11% of WIC personnel compared to 6.5% of non-wic personnel were black or African-American. Nearly one-quarter of the public health nutrition workforce intended to retire within the next 10 years. The mean age for the workforce was 42.2 years old (42.1 years old, WIC; 43.3 years old, non-wic). Almost one-quarter (23.9%) of the workforce reported intending to retire within the next 10 years and within 6.57 years on average. Non-WIC personnel reported a slightly greater intention to retire than did WIC personnel (28.5% vs. 23.3%). Approximately 31.2% of professionals and 19.2% of paraprofessionals intended to retire within the next 10 years. The greatest rates of retirement intention were for Public Health Nutrition Directors (44.6%) and Public Health Nutrition Assistant Directors (37.8%). Because the proportion of WIC nutrition personnel with 1-9 years of experience decreased and 24% reported intending to retire within 10 years, both retention and future leadership are important concerns.

10 4 Background The Association of State and Territorial Public Health Nutrition Directors (ASTPHND) in association with its federal partners, including the United States Department of Agriculture, Food and Nutrition Service (USDA, FNS) and the Maternal and Child Health Bureau of the United States Department of Health and Human Services (DHHS), has had a long-standing interest in the public health nutrition workforce. This document reports the results of the most recent census survey of the public health nutrition workforce conducted in by ASTPHND in collaboration with the Public Health Nutrition Program at The University of Tennessee, Knoxville. It was funded with partial support from USDA, FNS that was complemented by funding from ASTPHND and the University. The Collaborating Partners in the Census Enumeration ASTPHND was founded in 1952 as a 501 (c)(3) non-profit membership organization to provide national and state leadership on food and nutrition policy, programs, and services to achieve optimal health through optimal nutrition for everyone in the United States. The Association is affiliated with the Association of State and Territorial Health Officials, as well as its family of state director organizations. ASTPHND members include the nutrition director or designee appointed by the chief health official of each U.S. state, territory, possession, and the District of Columbia. Nutrition directors are nutrition professionals who are functionally responsible for directing the nutrition programs of their state health agencies. Other members include state health agency employees responsible for administration and/or consultation for part of the agency s nutrition program(s). ASTPHND s Strategic Plan includes three priorities directly related to enumerating the public health nutrition workforce. These are: Developing a multi-disciplinary, culturally competent workforce to address public health nutrition issues. Developing resources and programs that enable State Health Agencies to provide effective, visible leadership for healthy eating and physical activity. Providing a strong, proactive voice to advance national policies, initiatives, resources and programs that help states and localities effectively address issues related to nutrition and physical activity. State and territorial public health nutrition directors are responsible for assessing the public health nutrition workforce within their states/territories. In addition, they must coordinate variously funded nutrition programs, services and policies. They also serve as the link between local, state and national nutrition programs, most notably the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Data from this survey are useful to state/territorial nutrition directors in evaluation of current recruitment and retention methods, developing training to meet identified needs, and advising policymakers. Consistent with the results of previous ASTPHND workforce surveys, WIC employed nearly 90% of the workforce; therefore, state/territorial directors often work with WIC officials in program implementation, as well.

11 5 The USDA, FNS is responsible for the administration of the WIC program. An area of improvement identified by FNS is improved diversity of its workforce. The public health nutrition workforce survey enumerates the workforce, including its age, gender, race, ethnicity, and languages spoken. In addition, to ensure a well-trained, high-quality workforce, FNS has targeted recruitment and retention of WIC personnel since Data from this survey include training, education, salaries, and years of experience, which aid in evaluation of existing recruitment and retention strategies. The WIC Program is a federally funded nutrition assistance program created by Congress in 1972 to serve nutritionally at risk low-and moderate-income pregnant, breastfeeding, and postpartum women, infants, and children up to age five. WIC Program participants receive healthy supplemental foods, nutrition education, breastfeeding information and support, and referrals to health care. Funding for the WIC Program has increased from $20.6 million in fiscal year (FY) 1974 to $5.3 billion in FY The ASTPHND public health nutrition workforce survey provides the only comprehensive source of workforce data on the public health nutrition workforce in WIC. WIC is the predominant funding source for the workforce overall. The Public Health Nutrition Program in the Department of Nutrition at the University of Tennessee, Knoxville, was a collaborator in this project. The Department of Nutrition previously collaborated with ASTPHND to describe the results of the 1994 workforce study. In the current census, the Department of Nutrition s specific roles were to: 1) oversee all aspects of developing, piloting, and collecting census data using the web-based survey instrument; 2) provide technical support and assistance to ASTPHND, State agency staff and survey respondents; 3) coordinate research and data analysis; and complete interim and project final reports for submission to the ASTPHND Data and Epidemiology Committee and USDA. The Department of Nutrition also filed application for approval of the project for human subject research, which was granted by the University s Institutional Review Board. The Public Health Nutrition Program has been active in the education and training of future public health nutrition personnel since This collaboration is an example of its commitment to the public health nutrition workforce infrastructure. Past Experience in Public Health Nutrition Workforce Enumeration and Special Interests ASTPHND has profiled the public health nutrition workforce since The last survey conducted was in The report, Survey of the Public Health Nutrition Workforce: was released in January It is the only comprehensive source of workforce data on nutritionists in state and local public health agencies. Data were collected through ASTPHND from state public health nutrition directors for the surveys administered from 1985 through The workforces described in 1985 and 1987 were limited to personnel in full-time budgeted positions employed in governmental health agencies, who provided predominantly population-based services. In 1991 ASTPHND members requested that the profile expand in scope to include more information for planning personnel training, advocating for additional personnel resources, developing recruitment and retention plans, and assessing ability to achieve program goals. As a result, questions were added to collect information on training needs, years of experience, racial-ethnic background, job classification, and funding source. Demographic

12 6 information on race, ethnicity and language were added to the survey instrument in In 1994 and the personnel surveyed also broadened and included those in both full-time and part-time positions, who were employed in or funded by governmental health agencies, and who provided both direct care and population-based services. From 1985 through 1991, the University of North Carolina at Chapel Hill School of Public Health worked with ASTPHND to collect and analyze data. In 1991 and 1994, the U.S. DHHS, Health Resources and Services Administration, Maternal and Child Health Bureau provided support to ASTPHND to administer the survey. Results from the 1994 workforce survey were described in a peer-reviewed publication by collaborators from The University of Tennessee, Knoxville, University of Minnesota, and ASTPHND. In and again in , USDA, FNS and ASTPHND developed cooperative agreements to support survey administration. USDA s Objectives USDA, FNS requires workforce information to provide technical assistance to improve state agency administrative systems, including recruitment and retention of qualified nutrition staff. To that end, USDA, FNS provided support to ASTPHND to monitor trends in the workforce. The resulting profile of the public health nutrition workforce will be useful to USDA, FNS in determining the extent to which personnel possess the necessary qualifications to fulfill the mission of the WIC Program. In addition, FNS, WIC was interested in the characteristics of Breastfeeding Peer Counselors. The WIC Program has historically promoted breastfeeding, but has emphasized it since it developed the Loving Support Model for a Successful Peer Counseling Program in Therefore, Breastfeeding Peer Counselor was added to the list of position classifications used in previous survey administrations. Nutrition Objectives and Healthy People 2010 Healthy People 2010 outlines national health objectives for the United States in an effort to identify and reduce the most significant preventable threats to health. Public health nutrition professionals and paraprofessionals have a special role in ensuring that the U.S. population reaches these health objectives. They include both professionals and paraprofessionals with unique expertise important for primary and secondary prevention, including nutrition screening, assessment, and intervention. Some public health nutrition personnel, particularly those with dietetic registration credentialing, are involved in tertiary prevention, especially for those with special health care needs. The work of public health nutrition personnel focuses on population/system-based interventions and direct client programs and services. Public health nutritionists are leaders at national, state and community levels in ensuring people in the United States achieve healthy diets and physically active lifestyles. One goal of Healthy People 2010 is to ensure that Federal, Tribal, State and local health agencies have the infrastructure necessary to provide effective essential public health services. This includes a well-trained, educated, skilled public health nutrition workforce. The data reported in this document provide information on the extent to which the current workforce possesses these attributes.

13 7 The current enumeration of the public health nutrition workforce was modeled on the enumeration. With the addition of year born to the survey items, the survey instrument now contains each of the core data elements recommended in Enumerating the Public Health Workforce, prepared by the Public Health Society and the Center for Health Leadership and Practice for the U.S. Department of Health and Human Services Health Resources and Services Administration (Table 1) 1. Table 1. Core Data Elements Recommended in Enumerating the Public Health Workforce Compared to Data Collected in the ASTPHND Survey. Recommendations from Enumerating the Public Health Data Elements in ASTPHND s Survey Workforce Total number of staff Yes, by state, agency, job class and other variables FTEs Yes, by funding source Occupation class Job function Location Age Education level Credentials Experience Salary range Ethnicity Race Gender Language Yes, 10-category scheme Yes, 14 categories of practice, percent time in direct service, type of client population, budget responsibilities, FTEs supervised or line responsibility Yes, state, type of agency of employment, type of work setting Yes, year born Yes, degrees completed, public health degrees completed, degrees working toward, completion of 5 core public health courses at undergraduate or graduate level Yes, 12 certifications relevant to nutrition, steps toward RD or DTR Yes, years in nutrition, public health nutrition, WIC programs Yes, by job classification as annual earned salary and minimum and maximum position salary; some improbably low annual salaries Yes, Latino Yes, OMB 2 approved categories Yes Yes, primary and any secondary, sufficient fluency to do job Similar to Table 1 in Survey of the Public Health Nutrition Workforce , Atchinson C, Gebbie K, Thielen L, Woltring C. Enumerating the Public Health Workforce. Health Resources and Services Administration, U.S. Dept. of Health and Human Services. April The Federal Office of Management and Budget at

14 8 Goals The goals of ASTPHND s workforce study were: To identify trends in the public health nutrition workforce. To determine the capacity of the public health nutrition workforce in accomplishing program goals and meeting priority needs To identify training needs of WIC personnel in relation to their job responsibility, credentials, education, and longevity To measure qualifications of WIC nutrition staff in all states and territories. To evaluate use of a Web-based survey strategy to collect and analyze personnel data. To assist USDA and state public health agencies in planning and evaluating their recruitment and retention efforts.

15 9 Study Methods The public health nutrition workforce survey was a census of all public health nutrition personnel in the US states, its territories, and Tribal organizations in a public health nutrition program or service under the purview of the state or territory s official health agency. All worked as either nutrition professionals or paraprofessionals. This target population was consistent with the 1994 and public health nutrition workforce surveys conducted by ASTPHND. All personnel in this target population were asked to complete the survey instrument in partial fulfillment of their job responsibilities. Support personnel in other professions and individuals trained in nutrition but not functioning in nutrition-related positions were not included. Both contracted workers and full- and part-time employees at the state, regional, and local levels were included in the survey. In addition, information was provided on any vacant positions meeting the target population definition by state or local directors. The survey Project Team consisted of ASTPHND s Executive Director, the Chair of ASTPHND s Data and Epidemiology Committee, and two public health nutrition researchers from The University of Tennessee, Knoxville. The Project Team was responsible for survey development and implementation, data collection, data management and cleaning, and reporting results. Members of the ASTPHND Data and Epidemiology Committee provided feedback and guidance on both survey development and implementation. A Nutrition Specialist with the Food and Nutrition Service of the US Department of Agriculture facilitated project movement through the federal approval processes of Federal Register and Office of Management and Budget reviews. The Project Team developed a 42-item, fixed response survey instrument for the census. The survey instrument was designed in large part from the survey instrument to enable comparisons of the two workforces. The Project Team also considered how the instrument could be developed and administered to minimize respondent burden and to be applicable across states and territories. Where possible, survey items in the and instruments were the same. In cases where items in the previous instrument proved problematic for respondents, the items were reviewed and revised to address the problems. In some cases new items were proposed in response to trends in the field or for more detailed information. For example, this survey included new items on employee benefits, year born, and retirement intention. Items on salary compensation were revised to reflect broadbanding of salaries in some states. To expedite survey implementation, decrease respondent burden, and improve the data collection and analysis process, the survey was administered primarily in a Web-based, online format. Survey design, conversion of the print survey format to Web-based format, and implementation were guided by members of ASTPHND S Data and Epidemiology Committee (See Appendix A for a list of the committee members). Pilot testing indicated that the print survey required 26.2 minutes to complete, while the Web-based version required 20.6 minutes. Though intended to be administered primarily on-line, a print version of the survey (Appendix C) was available for personnel without Internet access or for whom there were concerns about their ability to understand items or interact with computers. Arrangements were made with the

16 10 Project Team for data entry of completed print surveys into the Web-based format by designated state personnel. Some agencies requested permission to administer the survey in a group format to minimize any potential language barriers. Careful instructions were provided by the Project Team to prevent any breach of confidentiality and to maintain human subjects protection. The survey instructions and then each individual survey item were read orally by a group leader to nutrition personnel who were seated so that their responses entered onto their own print copies of the survey were not visible to anyone else in the room. Following this oral administration of the survey, respondents sealed their completed surveys in blank envelopes and provided them to the group leader. The group leader then submitted all sealed surveys to the state designee for dataentry of the individual completed surveys. An abbreviated, 11-item version of the 42-item survey was developed to capture data about vacant positions and completed by state personnel or local agency directors. This vacant position survey could be completed on-line or in print formats. If they were completed in print format, then, like the print versions of the 42-item survey, these completed surveys were returned to each state s designee, where arrangements were made for data entry. Survey items for the filled position and vacant position surveys collected three categories of information: position information, regardless of whether the position was filled or vacant; more detailed information for filled positions; and information on the individual responding to the survey, except for those completing the vacant position survey. Because an individual could work in multiple positions, a shortened 28-item version of the 42-item survey that captured position-specific data only was developed. This reduced the respondent burden, because personnel holding multiple positions did not need to complete the full 42-item survey for each position. Instead they could answer the complete 42-item version for one position and then the shorter 28-item position survey for the other positions held.. Because of the on-line format, data collection did not require state-level entry, as in the past, except for those surveys completed in print format. As in previous survey administrations, State Contacts reviewed responses to pre-selected items as part of data cleaning. These included items on salary and source of funding, because they had required the most data cleaning in the past. However, unlike previous administrations when state personnel reviewed and edited completed print surveys, in this survey administration State Contacts used electronic monthly reports generated by The University of Tennessee researchers that included individuals responses to the pre-selected items. State Contacts cleaned these data files as appropriate and returned them to the University, where the overall data base was revised. State contacts also maintained a master file of the monthly reports to assist in monitoring, promoting, and reporting state response rates. Training materials for state and territorial directors/designees regarding survey administration within states were available on-line ( in July 2006, prior to a series of 10 training conference calls held August through September. Training materials consisted of: Workforce Survey Orientation (PowerPoint file) Workforce Survey Instructions for Data Collection (MS WORD file) Sample Communications with Nutrition Staff Members (MS Word file) Sample Communications with Local Agency Directors file (MS Word file) Filled Position Survey (pdf)

17 11 Filled Position Master File (Excel file) Sample State Monthly Report (Excel file) Vacant Position Survey (pdf) Vacant Position Master File (Excel file) State directors/designees were instructed to designate a State Contact responsible for survey administration and survey-related communication with ASTPHND within their state. The survey was available on-line from September 2006-March Data collected during the survey were housed on The University of Tennessee, Knoxville server using the mrinterview on-line survey program (mrinterview ver. 4.0, , SPSS Ltd., Chicago, IL) and edited in SPSS version 15.0 (SPSS 15.0 for Windows, ver , November 22, 2006, SPSS Inc., Chicago, IL). All 50 states and 6 territories were asked to participate. Unlike the workforce survey, Indian Tribal Organizations were captured within the state in which they were located. Each state/territory-specific response rate was calculated as the proportion of filled positions surveyed that were completed. Vacant positions were not included in response rate calculations. The overall response rate was 80.0% (10,312/12,886 positions) (Table 2); state/territory response rates ranged from 29.8% to 100%. All 50 states and 1 territory participated. The only state not participating in the survey, Idaho, participated in this census. Data were analyzed using SPSS (SPSS 15.0 for Windows, Release , SPSS Inc., November 22, 2006). Descriptive, univariate and bivariate analyses were performed to be consistent with the survey. Because of the large presence of workers in the WIC program, results are reported for the public health nutrition workforce overall and for the WIC and non-wic workforces. The survey instruments for filled and vacant positions should be used in conjunction with reported results in all interpretations of the survey findings. Readers are advised also to note the denominator used in the analysis of each survey item. Analyses for some items were based on responses about both filled and vacant positions (n=10,683), while others were based only on responses about filled positions (n=10,312 filled positions; n=371 vacant position). In addition, some items referred to person characteristics (such as education and demographics), while others referred to position characteristics (such as supervisory or fiscal responsibilities). Because there were some individuals who held multiple positions, the number of persons is less than the number of positions. A total of 119 persons worked in multiple positions and completed the survey once for each survey; 10,193 persons worked in 10,312 positions. An advantage to the on-line format was that responses to items could be required for forward movement in the survey instrument, thus limiting item non-response. However, to limit respondent burden not all items required responses. This included, for example, the items on ethnicity and race, in part because they were viewed as sensitive items and with high item nonresponse rates in the previous survey administration. Items that did not require responses for forward movement in the on-line survey were analyzed to include non-responses. Therefore, results in tables include non-responses for these items. The study design is described in greater detail in Appendix D.

18 12 Table 2. Response Rates Reported by States for Filled Positions State Responses Total Positions Response Rate State Responses Total Positions Response Rate Alaska % Mississippi % Alabama % Montana % Arkansas North % Carolina % North Dakota Arizona % % California % Nebraska % Colorado % New Hampshire % Connecticut % New Jersey % District of New Mexico Columbia % % Delaware % Nevada % Florida % New York % Georgia % Ohio 240 NAv --- Guam*** % Oklahoma % Hawaii % Oregon % Iowa % Pennsylvania % Idaho % Rhode Island 48 NAv --- South Illinois % Carolina % Indiana % South Dakota % Kansas % Tennessee % Kentucky % Texas % Louisiana % Utah % Massachusetts % Virginia % Maryland % Vermont % Maine % Washington % Michigan % Wisconsin % West Virginia % Minnesota % Missouri % Wyoming % Total* % Similar to Table 2 in Survey of the Public Health Nutrition Workforce , * Total is based on filled public health nutrition positions.

19 13 Study Findings The purpose of this section is to describe the public health nutrition workforce overall and with comparisons of the WIC and non-wic workforces. The survey was designed in part to describe how the workforce had changed since the previous survey in To this end, many of the survey items were the same for the two time periods. Therefore, each table in these Study Findings that is similar to one from the Study Findings references the corresponding table number from that report. It is important to remember, however, that the two surveys were administered in very different modes (print in and on-line in ) and the overall response rates differed (88.0% in and 80.0% in ). Therefore, all comparisons presented in the following findings must be used with caution. They are informative, however, given the large number of respondents in both surveys and the relatively high response rates. WIC s Presence in the Public Health Nutrition Workforce Almost 90% (88.6%) of all of the reporting positions, including full-time, part-time and vacant positions, worked in WIC at the time of the survey (Table 3). This represents a decrease from , when 90.4% of the positions were in WIC, but an increase from 1994 when 85.4% of respondents reported WIC as their area of practice. Despite the current decrease, WIC remains the overwhelming program of work for the workforce. Table 3. WIC and Non-WIC Job Functions (Question 7) WIC and Non-WIC Job Functions N % WIC* % Non-WIC % Total** % Similar to Table 3 in Survey of the Public Health Nutrition Workforce , * Includes non-wic funded persons and positions. ** Total is based on filled and vacant public health nutrition positions. Agency of Employment and Primary Work Location of the Public Health Nutrition Workforce As shown in Table 4, more than two-thirds of workforce positions (69.0%) were employed (or contracted) by official health agencies at the state and local levels, consistent with the workforce. Most of these (41.9%) were employed by local health agencies. Similarly, most of the WIC positions (43.5%) were employed at the local level rather than the state level (26.0%). In contrast most non-wic positions were employed at the state level (35.0%) compared to the local level (29.2%). The other primary agency that employed nutrition personnel was non-profit organizations, which employed or contracted about one-quarter of positions overall (25.1%) and of WIC (25.5%) and non-wic (21.9%) positions. Compared to , proportionately more positions were employed by state health agencies (27.1% vs. 19.9%), while less were employed by local health agencies (41.9% vs. 47.9%) and non-profit organizations (25.1% vs. 28.4%). These changes mirrored the changes for WIC positions, but contrasted with the changes

20 14 for non-wic positions, where state health agencies employed slightly less (35.0% vs. 36.6%) and non-profit organizations employed more (21.9% vs. 18.5%) positions. Respondents had the option to select other for employment agency and, although this was a small percent of positions (3.8%), this was an increase from 1.4% in Primary work location of the WIC and non-wic workforces, therefore, differed with proportionately more WIC positions at the local level and more non-wic positions at the state level. Table 4. Agency of Employment (Question 1) WIC/Non-WIC WIC Non-WIC Total Agency type N % N % N % State government health agency % % % Local government (city, county) health agency % % % Indian Health Services, tribal agency or tribal health center % % % Non-profit organization % % % For-profit organization % 8 0.7% % Other % % % Total* % % % Similar to Table 4 in Survey of the Public Health Nutrition Workforce , * Total is based on filled and vacant public health nutrition positions. Although public health nutrition personnel may be employed by a particular type of agency, their place of employment can differ. For example, personnel may work at a county-level health agency, but be employed by the state health agency. Table 5 describes the primary location or physical site where personnel work. More than half (53.4%) of positions overall and within WIC (53%) were located at central offices of state, district/regional, and local health agencies or field office/clinics of government health agencies. Over one-quarter (26.5%) of positions overall and within WIC (28.7%) were located at community/rural/migrant health centers or clinics. These proportions were similar for non-wic positions, although the distributions within these location categories differed with more non-wic compared to WIC positions located at the central office of a state government health agency (21.9% vs. 5.6%) and fewer positions located at the central office of a local government health agency (22.5% vs 30.1%), field office or clinic of a government health agency (7.2% vs 14.5%), and community/rural/migrant health centers or clinics (8.6% vs. 28.7%).

21 15 Table 5. Primary Work Location (Question 2) WIC/Non-WIC WIC Non-WIC Total Primary location N % N % N % Central office of state government health agency % % % Central office of district or regional (sub-state) government % % % Central office of local (county, city or multi-county) government % % % Community/rural/migrant health center or clinic % % % Field office or clinic of a government health agency % % % HMO* or other managed care setting % 0 0.0% % Hospital % % % Indian Health Services, tribal agency or tribal health center % % % Other private/independent entity/office % % % Other % % % Total** % % % Similar to Table 5 in Survey of the Public Health Nutrition Workforce , * Health Maintenance Organization **Total is based on filled and vacant public health nutrition positions. Job Classification of the Public Health Nutrition Workforce Respondents were asked to classify their job from a list of position descriptions, but without any designation of a particular job classification. These position descriptions corresponded with 9 job classifications described in Personnel in Public Health Nutrition for the 1990 s 3 and a single job classification (Breastfeeding Peer Counselor) used by the Food and Nutrition Service, USDA (Table 6). Respondents also had the option to select Other and then to describe the job performed. 3 Prior to survey administration these job classifications were still considered relevant and appropriate by the Data and Epidemiology Committee. During survey administration a national committee was convened to review and update Personnel in Public Health Nutrition for the 1990 s. At the time of writing the survey s final report, the revision was not completed. However, the committee Chair, Dr. Janice Dodds, University of North Carolina, confirmed that minor revisions in the position descriptions would be in the final and revised document. Therefore, the position descriptions and classifications were not considered time-limited for the purposes of the current survey administration.

22 16 The primary focus of the job classifications differed. The job classifications with Public Health Nutrition in the title had more population/system-focused responsibilities, while the other job classifications had more direct care/client-focused responsibilities. Each can be categorized within a job series, including Management Series (Public Health Nutrition Director, Assistant, and Supervisor), Professional Series (Public Health Nutrition Consultant, Public Health Nutritionist, Clinical Nutritionist, and Nutritionist), or Technical/Support Series (Nutrition Technician and Nutrition Assistant). To allow comparisons between professionals and paraprofessionals, jobs classified within the Management and Professional Series were collapsed into a Professional classification and jobs classified within the Technical/Support Series and also the Breastfeeding Peer Counselor job classification were collapsed into a Paraprofessional classification. Table 6. Titles and Descriptions of Public Health Nutrition Job Classifications From Personnel in Public Nutrition for the 1990s Title of job classification Public Health Nutrition Director Assistant Public Health Nutrition Director Public Health Nutrition Supervisor Public Health Nutrition Consultant Public Health Nutritionist Description The highest-level nutrition position in a state, large city, county or voluntary public health agency. Major functions of this position are policy-making, planning/evaluation, fiscal control, management and supervision. The position is usually the head of a nutrition program unit, where the director is responsible for conducting a needs assessment, developing a comprehensive plan and budget for the nutrition services of the agency and has line authority over staff. The second highest administrative and policy-making public health nutrition position in a state, large city, county or voluntary public health agency. The assistant director may participate in several delegated functions or be assigned primary responsibility for managing the nutrition component of one or more major program areas. The person in this position serves as Acting Director in the director's absence. Supervises the work of an assigned number of other nutritionists, nutrition technicians, and nutrition assistants that deliver nutrition services and nutritional care in the public health agency. Supervision includes training, delegating, directing, coordinating, evaluating and reporting the work of subordinates. Includes both generalized and specialized nutrition consultants who provide expert technical assistance, professional guidance, and in-service education in program development or case management. Consultation may be given to the administrator, other nutritionists or other health professionals. Consultants include those who work out of a central headquarters office or in the health agency s regional or district offices. A nutrition professional with academic training in public health who is employed by the state or local public health agency to assess the community's nutrition needs and to plan, direct and evaluate community nutrition intervention programs that meet these needs. Interventions promote health and prevent disease among the population at large.